UNIVERSITY OF MALTA FACULTY OF MEDICINE & SURGERY … · FACULTY OF MEDICINE & SURGERY PHARMACY DEPARTMENT Ref. No. SOP/PD/232_01 STANDARD OPERATING PROCEDURE ADVANCED VENEPUNCTURE

UNIVERSITY OF MALTA

FACULTY OF MEDICINE & SURGERY

PHARMACY DEPARTMENT Ref. No. SOP/PD/232_01

STANDARD OPERATING PROCEDURE

ADVANCED VENEPUNCTURE ARM Valid for:

2 years from

approval

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1. Scope

This Standard Operating Procedure (SOP) applies to staff and students using the

Advanced Venepuncture Arm in the Pharmacy Practice Resource Unit (PPRU) at the

Pharmacy Department, University of Malta.

2. Objective

To describe the procedure for set-up and use of the Advanced Venepuncture Arm.

3. Definitions

a. Red reservoir selector lever: Situated on the front of the fluid unit.

b. Venepuncture: Collection of blood from a vein; veins being the best source

from which to obtain blood.

c. Cannulation: Insertion of a hollow, narrow tube with a sharp, retractable

inner core (cannula) into a vein, artery, or another body cavity.

d. Median Cubital Vein: Vein of choice for venepuncture of the upper limb. It

is located in the preferred site which is the antecubital fossa, where the

arm bends at the elbow (SOP/PD/231_01/A1).

e. Mock Blood: A synthetic solution made to the correct colour and viscosity of

venous blood.

f. Injections: Sterile solutions, suspensions or emulsions, presented in a suitable

aqueous or non-aqueous vehicle intended for parenteral administration into

body tissues.

g. Intravenous Injection: Injection of a substance directly into the vein

(SOP/PD/231_01/A2). The intravenous route (IV) uses a hypodermic

injection for the purpose of instilling a single dose of medication, injecting a

contrast medium or beginning an IV infusion of blood, medication, or a fluid

solution, such as saline or dextrose in water.

h. Antecubital Fossa (ACF): A tiny cavity in the shape of a triangle located in

the elbow joint which is vital for blood samples because there are the three

main veins running through it. These are the cephalic vein, basilic vein and

median vein (SOP/PD/231_01/A3).

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4. Responsibility

4.1. The members of the Department of Pharmacy (staff and students) are

responsible for following this SOP.

4.2. The designated Laboratory Officer or Laboratory Assistant is responsible for

ensuring that this SOP is followed.

5. Procedure

5.1. Diagram of Advanced Venepuncture Arm

a. Advanced Venepuncture Arm Skin – Light

b. Advanced Venepuncture Arm Rest

c. Fluid Unit

d. Mock blood

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5.2. Basic Fluid Unit Operations

5.2.1. Connect the refill bottle or the arm to the fluid unit, ensuring that the

tube with the black sleeve attaches to the left connector with the black

ring on it.

5.2.2. Slide the red reservoir selector lever to the left to pressurise the left

reservoir or slide the red reservoir selector level to the right to

pressurise the right reservoir.

5.2.3. Turn the release valve clockwise to close it, before pressurising the

fluid unit, by squeezing the pressure bulb.

5.2.4. Turn the release valve anticlockwise to open; this will depressurise the

fluid unit.

5.3. Filling the Fluid Unit

5.3.1. Feed the blood into the left hand reservoir when filling the fluid unit.

5.3.2. Slide the reservoir selector to the right.

5.3.3. Connect the refill bottle.

5.3.4. Close the valve on the pressure bulb.

5.3.5. Pressurise the fluid unit into the grey zone.

5.3.6. Keep the pressure in the grey zone to ensure that the reservoir fills

quickly.

5.3.7. Open the pressure valve once the blood reaches a maximum level of

300ml to depressurise the fluid unit and the blood stops transferring.

5.3.8. Disconnect the bottle; the fluid unit is full and ready to be attached to

the arm.

5.4. Priming the Veins

5.4.1. Slide the red reservoir selector lever to the left after carrying out the

steps in Section 5.3.

5.4.2. Connect the arm.

5.4.3. Ensure that both white clips on the arm tubes are open.


5.4.5. Pressurise the fluid unit into the green zone. Do not overpressurise

(into the grey zone) as this will cause blood to leak from the puncture

sites in previously used veins creating a mess under the skin. Air

pressure in the left reservoir forces the blood out through the arm and

into the right reservoir.

5.4.6. Close the white clip on the right hand tube after there are no more air

bubbles coming out of the arm. This will maintain the correct pressure

in the arm during training and the arm is ready to use.

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5.5. Fitting the Skin

5.5.1. Lubricate the arm with the supplied water-based lubricant to make the

skin easier to attach; the hand, forearm and upper arm must be well

lubricated.

5.5.2. Align the skin with the underlying anatomy of the arm.

5.5.3. Work the skin up the arm gently.

5.5.4. Pull the fingers onto the hand.

5.5.5. Slide the skin up to the top of the arm; the ridge around the inside must

engage with groove at the top.

5.5.6. Slide the skin around slightly so that it fits the arm anatomy properly.

5.6. Using the Arm

5.6.1. Take the blood by using vacuum collection devices, or a needle and

syringe or by cannulation.

5.6.2. Maintain the pressure in the green zone during training since as the

blood level decreases in the left reservoir the pressure will drop.

5.6.3. Release the clip on the right hand tube occasionally during training and

allow blood to flow through the arm to remove any air bubbles that

might have been introduced.

5.6.4. Pressurise the arm from the right reservoir when there is a sufficient

volume of blood in it.

5.6.5. Slide the red reservoir selector lever to the right.

5.6.6. Open the clip on the right tube and close the clip on the left tube

ensuring the pressure is in the green zone.

5.6.7. Squirt the contents of the syringe into a container so that at the end of

the training session the blood can be poured back into the refill bottle.

5.7. Emptying the Veins Prior to Replacement

5.7.1. Slide the red reservoir selector to the right.

5.7.2. Connect the arm.

5.7.3. Ensure both white clips on the arm tubes are open.


5.7.5. Pressurise the fluid into the green zone. Air pressure in the right

reservoir forces the blood out through the arm and into the left

reservoir.

5.7.6. Release the pressure and disconnect the arm once the amount of blood

coming out is minimal; the right reservoir will eventually empty and

air will flow through the veins.

5.7.7. Disconnect the arm.

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5.8. Emptying the Fluid Unit Prior to Storage/Transport

5.8.1. Remove the blood from the fluid unit only when it is in the left hand

reservoir.

5.8.2. Slide the red reservoir selector lever to the left.

5.8.3. Connect the refill bottle.


5.8.5. Pressurise the fluid unit into the grey zone and keep the pressure in the

grey zone to ensure that the bottle fills quickly.

5.8.6. Release the pressure and disconnect the bottle once most of the blood

has been removed and only air is bubbling through the left tube.

5.9. Removing the Skin

5.9.1. Roll the upper part of the skin down over onto itself, as far as it will

go, using both hands. Do not force the skin.

5.9.2. Fold the skin down over onto itself again.

5.9.3. Gently pull the skin down onto the wrist.

5.9.4. Gently pull the skin off the wrist onto the hand; the hand should

gradually go floppy as the skin is worked off the arm.

5.9.5. Hold the skin by the upper part once most of the skin is off the arm,

and remove it.

5.10. Changing the Veins

5.10.1. Follow the procedures in Sections 5.7 and 5.9 before changing the

veins.

5.10.2. Remove and discard the strips of tape running around the thumb, wrist,

and the upper antecubital fossa (ACF) area.

5.10.3. Disconnect the two upper connectors first.

5.10.4. Pull the lower connector gently out of the palm.

5.10.5. Hold the transparent tube and pull the vein out from it.

5.10.6. Remove the vein and discard it. Avoid spilling any residual blood left

in the veins.

5.10.7. Lay the new vein on the work surface in the correct position (two veins

at the top, small hand veins at the bottom and the slant of the median

cubital matches the groove in the vein module).

5.10.8. Attach the top two veins and push the transparent tubes back into the

arm so that the connectors fit well.

5.10.9. Fit the veins into the grooves and wrap the supplied tape around the

upper ACF area to hold them in place.

5.10.10. Attach the palm connector and push the transparent tube back into the

arm so that the connector fits well.

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5.10.11. Fit the veins into the grooves of the forearm and tape them in place.

5.10.12. Tape the vein into the thumb area ensuring that the veins around the

hand fit in the grooves correctly.

5.10.13. Settle the veins into the grooves correctly; the arm is now ready to

have the skin fitted.

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5.11. Flow Charts

5.11.1. Basic Fluid Operations

Start

Connect the refill bottle or the arm to the fluid

unit, ensuring that the tube with the black

sleeve attaches to the left connector with the

black ring on it.

Slide the red reservoir selector lever, situated

on the front of the fluid unit, to the left to

pressurise the left reservoir or slide the red

reservoir to the right to pressurise the right

reservoir.

Turn the release valve clockwise to close it,

before pressurising the fluid unit, by squeezing

the pressure bulb.

End

Turn the release valve anticlockwise to open;

this will depressurise the fluid unit.

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5.11.2. Filling the Fluid Unit

Start

Slide the red reservoir selector lever to the

right.

Connect the refill bottle.

Close the valve on the pressure bulb.

Pressurise the fluid unit into the grey zone.

Open the pressure valve once the blood

reaches a maximum level of 300ml to

depressurise the fluid unit and the blood stops

transferring.

Disconnect the bottle; the fluid unit is full and

ready to be attached to the arm.

End

Feed the blood into the left hand reservoir

when filling the fluid unit.

Keep the pressure in the grey zone to ensure

that the reservoir fills quickly.

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5.11.3. Priming the Veins

Start

Slide the red reservoir selector lever to the left

after carrying out the procedure in Section

5.11.2

Connect the arm

Ensure that both white clips on the arm tubes

are open


Pressurise the fluid unit into the green zone.

Do not overpressurise (into the grey zone) as

this will cause blood to leak from the puncture

sites in previously used veins creating a mess

under the skin. Air pressure in the left

reservoir forces the blood out through the arm

and into the right reservoir.

Close the white clip on the right hand tube

after there are no more air bubbles coming out

of the arm. This will maintain the correct

pressure in the arm during training and the arm

is ready to use.

End

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5.11.4. Fitting the Skin

Start

Lubricate the arm with the supplied water-

based lubricant to make the skin easier to

attach. The hand, forearm and upper arm must

be well lubricated.

Align the skin with the underlying anatomy of

the arm.

Work the skin up the arm gently.

Pull the fingers onto the hand.

Slide the skin up to the top of the arm. The

ridge around the inside must engage with

groove at the top.

Slide the skin around slightly so that it fits the

arm anatomy properly.

End

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5.11.5. Using the Arm

Start

Take the blood by using vacuum collection

devices, or a needle and syringe or by

cannulation.

Maintain the pressure in the green zone during

training since as the blood level decreases in

the left reservoir the pressure will drop.

Release the clip on the right hand tube

occasionally during training and allow blood

to flow through the arm to remove any air

bubbles that might have been introduced.

Pressurise the arm from the right reservoir

when there is a sufficient volume of blood in

it.


right.

End

Open the clip on the right tube and close the

clip on the left tube ensuring the pressure is in

the green zone.

Squirt the contents of the syringe into a

container so that at the end of the training

session the blood can be poured back into the

refill bottle.

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5.11.6. Emptying the Veins Prior to Replacement

Start


right

Connect the arm

Ensure both white clips on the arm tubes are

open.


Release the pressure and disconnect the arm

once the amount of blood coming out is

minimal. Eventually the right reservoir will

empty and air will flow through the veins.

Disconnect the arm

End

Pressurise the fluid into the green zone. Air

pressure in the right reservoir forces the blood

out through the arm and into the left reservoir.

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5.11.7. Emptying the Fluid Unit Prior to Storage/Transport

Start

Slide the red reservoir selector lever to the left.

Connect the refill bottle.


Pressurise the fluid unit into the grey zone and

keep the pressure in the grey zone to ensure

that the bottle fills quickly.

Release the pressure and disconnect the bottle

once most of the blood has been removed and

only air is bubbling through the left tube.

End

Remove the blood from the fluid unit only

when it is in the left hand reservoir.

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5.11.8. Removing the Skin

Start

Roll the upper part of the skin down over onto

itself, as far as it will go, by using both hands.

Do not force the skin.

Fold the skin down over onto itself again.

Gently pull the skin down onto the wrist.

Gently pull the skin off the wrist onto the

hand; the hand should gradually go floppy as

the skin is worked off the arm.

Hold the skin by the upper part once most of

the skin is off the arm, and remove it.

End

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5.11.9. Changing the Veins

Start

Follow the procedures in Sections 5.11.6. and

5.11.8. before changing the veins.

Disconnect the two upper connectors first.

Pull the lower connector gently out of the

palm.

Remove the vein and discard it. Avoid spilling

any residual blood left in the veins.

Lay the new vein on the work surface in the

correct position (two veins at the top, small

hand veins at the bottom and the slant of the

median cubital matches the groove in the vein

module).

Attach the two top veins and push the

transparent tubes back into the arm so that the

connectors fit well.

Remove and discard the strips of tape running

around the thumb, wrist, and the upper

antecubital fossa (ACF) area.

Hold the transparent tube and pull the vein out

from it.

1

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Fit the veins into the grooves and wrap the

supplied tape around the upper ACF area to

hold them in place.

Attach the palm connector and push the

transparent tube back into the arm so that the

connector fits well.

Fit the veins into the grooves of the forearm

and tape them in place.

Tape the vein into the thumb area ensuring that

the veins around the hand fit in the grooves

correctly.

Settle the veins into the grooves correctly. The

arm is now ready to have the skin fitted.

End

1

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6. Precautions

6.1. Always set the arm up on a wipe clean surface since the process is potentially

messy.

6.2. If mock blood gets into the eyes flush with plenty of cold water.

6.3. Do not wear ‘good’ clothes when training with this product since contact with

mock blood will permanently stain them. It can be washed out using a

biological detergent.

6.4. Observe normal hygiene procedures after handling the product and mock

blood.

6.5. Do not overpressurise into the grey zone when priming the veins as this will

cause blood to leak from the puncture sites in previously used veins creating a

mess under the skin.

6.6. Maintain the pressure in the green zone during training since as the blood level

decreases in the left reservoir the pressure will drop.

6.7. When emptying the fluid unit the blood to be removed must always be in the

left hand reservoir.

6.8. Do not force the skin when rolling the upper part of the skin down over onto

itself to remove it.

6.9. The fluid unit should always be emptied before storing the arm in its

appropriate case, especially if the product is being transported long distances.

6.10. Avoid spilling any residual blood left in the veins whilst removing to discard

them.

7. References

Advanced Venepuncture Arm User Guide. Issue 2. UK; Limbs & Things Ltd;

2008.

The Venipuncture From an Arm Vein. So You’re Going to Collect a Blood

Specimen: An Introduction to Phlebotomy. [Online]. 2013 [cited 2013 Oct

15];21-23. Available from: URL:

http://www.cap.org/apps/docs/cap_press/bloodSpecimenBook/Venipuncture.p

df

Venepuncture Year 2 Dental Students Practical Skill Session. University

Section of Anaesthesia, Pain & Critical Care Medicine. Clinical Skills in

Venepuncture & IV Cannulation. [Online]. [cited 2013 Nov 20]. Available

from: URL: http://www.gla.ac.uk/media/media_109798_en.pdf

http://www.cap.org/apps/docs/cap_press/bloodSpecimenBook/Venipuncture.pdf

http://www.cap.org/apps/docs/cap_press/bloodSpecimenBook/Venipuncture.pdf

http://www.gla.ac.uk/media/media_109798_en.pdf

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8. Appendices

SOP/PD/231_01/A1 – Diagram showing the median cubital vein

SOP/PD/231_01/A2 – Diagram showing the desired angle and site for venepuncture

SOP/PD/231_01/A3 – Diagram showing The Antecubital Fossa

9. Revision History

Version Number Amendments/ Reasons for change

01 Initial Release

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SOP/PD/231_01/A1 - Diagram showing the median cubital vein

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SOP/PD/231_01/A2 - Diagram showing the desired angle and site for venepuncture

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SOP/PD/231_01/A3 - Diagram showing The Antecubital Fossa

UNIVERSITY OF MALTA FACULTY OF MEDICINE & SURGERY … · FACULTY OF MEDICINE & SURGERY PHARMACY DEPARTMENT Ref. No. SOP/PD/232_01 STANDARD OPERATING PROCEDURE ADVANCED VENEPUNCTURE

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